Healthcare Management: An Introduction
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In the following sections, we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members.
Which of the following is the best description of what a 'Process measure' evaluates?
As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric im
Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:
A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services.
With regard to the steps that the health plan's claims e
A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must
A physician-hospital organization (PHO) may be classified as an open PHO or a closed PHO. With respect to a closed PHO, it is correct to say that
Allgood Medical, Inc., a health plan, has contracted with Mercy Memorial Hospital to provide inpatient medical services to Allgood's plan members. The terms of the contract specify that Allgood will reimburse Mercy Memorial on the basis of a negotiated ch
If a state commissioner of insurance places an HMO under administrative supervision, then the purpose of this action most likely is to:
Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:
Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that
From the answer choices below, select the response that correctly identifies the rating method that Mr. Sybex used and the premium rate PMPM that Mr. Sybex calculated for the Koster group.
Health plans require utilization review for all services administered by its participating physicians.
Arthur Moyer is covered under his employer's group health plan, which must comply with the Consolidated Omnibus Budget Reconciliation Act (COBRA). Mr. Moyer is terminating his employment. He has elected to continue his coverage under his employer's group
Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typically
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On October 23, Holt used the following information to calculate the bed days per
By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care include
Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.
D.
, in an effort to recruit her as a PCP in GreenWhich of the following job descriptions best match the job of a telephone triage staff member?
The following statement(s) can correctly be made about the characteristics of reports that should be provided to managers for use in managing a healthcare delivery system:
The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the hi
The following statements are about the non-group market for managed care products in the United States. Select the answer choice containing the correct statement.
The NAIC designed a small group model law to enable small groups to obtain accessible, yet affordable, group health benefits. Specifically, the model law limits the rate spread. According to this model law, if the lowest rate that an HMO charges a small g
Which of the following population groups are eligible for Medicare coverage
The following statements describe individuals who are applying for individual health insurance coverage:
Six months ago, Wilbur Lee lost his health insurance coverage due to a reduction in work hours and has exhausted his coverage under COBR
A.
Mr. Lee hasThe National Association of Insurance Commissioners' (NAIC's) Unfair Claims Settlement Practices Act specifies standards for the investigation and handling of claims. The Act defines unfair claims practices and notes that such practices are improper if the
The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues related to overall organizational policy. The Corporate Compliance Committee are convened to address specific management concerns. The following statement(s) can correctly be made about these committees:
Which of the following statements about Family and Medical Leave Act (FMLA) is WRONG?
The Mirror Health Plan uses a form of computer/telephony integration (CTI) to manage telephone calls coming into its member services department. When a member calls the plan's central telephone number, a device answers the call with a recorded message and
Medigap policies were standardized into ten standard benefit pl ranging from A-J by the ____
Which of the following statements is NOT a requirement for a service to be deemed a 'medically necessary service'?
The health plan determines what it considers to be the acceptable fee for a service or procedure and the physician agrees to accept that amount as payment in full for the procedure
The following statement can be correctly made about Medicare Advantage eligibility:
The contract between the Honolulu MCO and Beverley Hills Hospital contains a 90 day cure provision. The Beverley Hills Hospital breached one of the contract requirements on July 31, 2004. The hospital remedied the problem by October 31, 2004. Which of the
One non-group market segment to which health plans market health plan products is the senior market, which is comprised mostly of persons over age 65 who are eligible for Medicare benefits. One factor that affects a health plan's efforts to market to the
One typical characteristic of preferred provider organization (PPO) benefit plans is that PPOs:
Janet Riva is covered by a traditional indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan.
Individuals can use HSAs to pay for the following types of health coverage:.
In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice containing the two terms that you have chosen. For providers, (operational /
The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be
One true statement about community rating, a rating method commonly used by health plans, is that:
The following programs are part of the Alcove Health Plan's utilization management (UM) program:
With regard to the UM programs, it is most
One device that PBM plans use to manage both the cost and use of pharmaceuticals is a formulary. A formulary is defined as
One typical characteristic of an integrated delivery system (IDS) is that an IDS.
PBM plans operate under several types of contractual arrangements. Under one contractual arrangement, the PBM plan and the employer agree on a target cost per employee per month. If the actual cost per employee per month is greater than the target cost, t
Medicare Part C can be delivered by the following Medicare Advantage plans:
One ethical principle in health plans is the principle of non-malfeasance, which holds that health plans and their providers:
One component of information systems used by health plans incorporates membership data and information about provider reimbursement arrangements and analyzes transactions according to contract rules. This information system component is known as
TESTED 26 Apr 2024
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